Telehealth and Consent Form

Telemedicine and Consent Form
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Legal Guardian (if applicable ie: child, disability etc.)

First NameLast Name
Legal Guardian relationship to the patient
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Name of preferred pharmacy:*
Pharmacy address:*

Street Address

Street Address Line 2

CityState

Zip Code
Phone # of preferred pharmacy:*
Age:*
Gender:*

FemaleMale
First day of last menstrual period (if applicable):

MonthDayYear
Date
Pregnant?

YesNoMaybe
What are your symptoms / concerns today?*
When did your symptoms start?
Allergies to Medications?*

NoneYes (Please List)
Medication allergies and reaction:
Current Medications*

NoneYes (Please List)
Medication List:
Medical Conditions:*

NoneHeart problemsLung problemsDiabetesHigh Blood PressureThyroid diseaseOther (Please List)
Medical conditions: (please list / describe)
Surgeries*

NoneYes (please list)
Surgeries (Please list):
Family Medical History*

NoneYes (please list)
Family Medical History (please list/describe):
Social History:
Smoke Cigarettes*
Number of cigarettes
Drink Alcohol*
Number of drinks
Recreational Drug Use*
Introduction to Telehealth

Telehealth is healthcare provided by any means other than a face-to-face visit. In telehealth services, medical and mental health information is used for diagnosis, consultation, treatment, therapy, follow-up, and education. Health information is exchanged interactively from one site to another through electronic communications. Telephone consultation, videoconferencing, transmission of still images, e-health technologies, patient portals, and remote patient monitoring are all considered telehealth services.
CONSENT FOR TELEHEALTH CONSULTATION

1.     I understand that I am voluntarily engaging in a telemedicine consultation with HIGH ALTITUDE MOBILE PHYSICIANS

2.     I understand that the video conferencing technology and/or phone consultations will not be the same as a direct patient/health care provider visit due to the fact that I will not be in the same room as my health care provider.

3.     I understand that a telehealth consultation has potential benefits including easier access to care, decreasing costs, and allowing visits to be performed from the comfort of my home.

4.     I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my health care provider or I can discontinue the telehealth consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.

5.     I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. I understand that if there is another individual present during the telehealth consultation that I will be informed of their presence and I will also disclose if there is another individual with myself. It is agreed that these individuals will maintain confidentiality of the information obtained. I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following: (1) omit specific details of my medical history/physical examination that are personally sensitive to me; (2) ask non‐medical personnel to leave the telemedicine examination room: and or (3) terminate the consultation at any time.

6.     I understand that the alternative to a telemedicine consultation is to forgo evaluation and treatment with HIGH ALTITUDE MOBILE PHYSICIANS and to seek out an in-person evaluation elsewhere. Thus, I am freely choosing to participate in a telemedicine consultation.

7.     I understand that telemedicine has limitations in regard to the physical examination. I understand that the physical exam portion of the care provided through HIGH ALTITUDE MOBILE PHYSICIANS will be limited to inspection via video conferencing and some parts of the exam such as physical tests, examination of certain body parts, and vital signs may be conducted by individuals at my location at the direction of the consulting health care provider or not done at all.

8.     Telemedicine services offered through HIGH ALTITUDE MOBILE PHYSICIANS are not an Emergency Service and in the event of an emergency or urgent medical issue, I will use a phone to call 911, go to the emergency department, or go to an urgent care.

9.     To maintain my privacy, I will not share telemedicine login information or video conferencing links with anyone unauthorized to attend the appointment.

By signing this form, I certify:

·       That I have read or had this form explained/read to me and I understand its contents including the risks and benefits of telemedicine.

·       That I have had the opportunity to ask questions and have had them answered to my satisfaction.

BY SIGNING BELOW, I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.

{patientName}

{dateOf}

Must be signed by legal guardian if patient is under age 18 or requires a legal guardian:

{legalGuardian}
Please sign:*

Clear
MEDICARE OPT OUT PRIVATE CONTRACT

• I, Leslie Shook and Danielle Shook (High Altitude Mobile Physicians), have been excluded from Medicare under §§1128, 1156 or 1892 of the Act.
• I, the beneficiary or the beneficiary’s legal representative accepts full responsibility for payment of the physician’s or practitioner’s charge for all services furnished by the physician/practitioner.
• I, the beneficiary or the beneficiary’s legal representative understands that Medicare limits do not apply to what the physician/practitioner may charge for items or services furnished by the physician/practitioner.
• I, the beneficiary or the beneficiary’s legal representative agrees not to submit a claim to Medicare or to ask the physician/practitioner to submit a claim to Medicare.
• I, the beneficiary or the beneficiary’s legal representative understands that Medicare payment will not be made for any items or services furnished by the physician/practitioner that would have otherwise been covered by Medicare if there was no private contract and a proper Medicare claim had been submitted.
• I, the beneficiary or the beneficiary’s legal representative enters into the contract with the knowledge that the beneficiary has the right to obtain Medicare covered items and services from physicians and practitioners who have not opted out of Medicare, and that the beneficiary is not compelled to enter into private contracts that apply to other Medicare-covered services furnished by other physicians or practitioners who have not opted out.
• The expected or known effective date and expected or known expiration date of the opt-out period is April 1, 2018 through April 1, 2026.
• I, the beneficiary or the beneficiary’s legal representative understands that Medigap plans do not, and that other supplemental plans may elect not to, make payments for items and services not paid for by Medicare.
• This contract cannot be entered into by the beneficiary or by the beneficiary’s legal representative during a time when the beneficiary requires emergency care services or urgent care services. (However, a physician/practitioner may furnish emergency or urgent care services to a Medicare beneficiary in accordance with §40.28;)
• I, the beneficiary or the beneficiary’s legal representative will receive or have received a copy (a photocopy permissible) of this contract, before items or services are furnished to me under the terms of this contract.
Patient Signature:

Clear
Please click Submit now. You will be redirected to the payment form.
Provider Assessment
Date:

MonthDayYear
Provider:
CC:
HPI:
General (abnormal vs, fever, anxious, tired etc.):

NormalAbnormal (specify)
HEENT:

NormalEyesAbnormal (specify)
Right Eye:

PainfulIrritatedForeign body sensationWears contactsBlurred visionLack of visionOrbital pain (bone)Mucoid drainageClear drainageRednessItchingOther symptoms (specify)
Left Eye:

PainfulIrritatedForeign body sensationWears contactsBlurred visionLack of visionOrbital pain (bone)Mucoid drainageClear drainageRednessItchingOther symptoms (specify)
Skin:

NormalAbnormal (specify)
Heart:

NormalAbnormal (specify)
Lungs / breathing:

NormalAbnormal (specify)
Neck / lymph nodes:

NormalAbnormal (specify)
Abdomen:

NormalAbnormal (specify)
Genital/ Urinary:

NormalUTI symptomsAbnormal (specify)
dysuriablood in urineurinary urgencyurinary frequencycloudy urineodor to urineflank painvaginal discharge
Neurologic:

NormalAbnormal (specify)
Musculoskeletal:

NormalAbnormal (specify)
Physical Assessment via audio or video:
Diagnosis:
Patient Education:
AMSURIPharyngitisUTIOrthoEYE
AMS Education:

Diet and hydration: Eat smaller, more frequent meals that are higher in carbs and lower in protein and fat (harder to digest). Sip on water throughout the day. Drinking too much too fast can cause stomach upset. Drink enough to keep your urine pale yellow to clear. For infants, watch for normal diaper count.Activity: It is recommended to limit strenuous activity the first 48 hours at altitude while your body adjusts. Unless on continuous oxygen, activity as tolerated after treatment.Sunglasses/ sunscreen: Sunburns and snow blindness are a serious risk at this altitude and with the sun reflecting off the snow.Alcohol: Alcohol slows your breathing rate which lowers your oxygen level. It can worsen your symptoms.Call your provider for any questions or concerns.Other
UTI Education:

Increase fluid intakeMay take AZO for urinary discomfort as directed for maximum of 3 daysIf you develop fever, vomiting or back pain, seek care in the emergency room.Contact provider with any questions or concernsOther
URI Education:

Ibuprofen or Tylenol as directed for discomfortIncrease hydrationOTC nasal steroid (ie: Flonase) as directed on packageGuaifenesin (Mucinex) as directed on packagePseudoephedrine (Sudafed) as directed on packageDextromethorphan (Delsym) as directed on packageOxymetazoline (Afrin nasal spray) as directed on package, no more than 3 consecutive daysContact provider with any questions or concernsOther
Pharyngitis Education:

Ibuprofen or Tylenol as directed for discomfortWarm-salt water gargles as needed for discomfortIf antibiotics ordered, switch to new toothbrush 24 hours after starting medicationContact provider with any questions or concernsOther
Ortho Education:

Ibuprofen or Tylenol as directed for discomfortGentle range of motion- not to the point of painIce for the first 24 hours- 20 minutes on, 20 minutes off while awakeKeep extremity elevated while restingNo weight bearingFollow up with orthopedist for re-evaluation asapContact provider with any questions or concernsOther
Eye Education:

Ibuprofen or Tylenol as directed for discomfortClean eyelids with warm water and paper towel and disposeWash hands frequently and avoid touching eyesDispose of contacts and wear only glasses until infection completely resolvedDispose of eye make up as it will be contaminatedAny loss or change of vision seek emergency care immediatelyContact provider with any questions or concernsOther
ICD-10 Diagnosis Code (Eye):
ICD-10 Diagnosis Code:
Other ICD-10
Other ICD-10 code
Other ICD-10 code
Other ICD-10 code
Plan:
RX:
Follow up:
CPT Procedure Code:
Should be Empty:

Telemedicine and Consent Form

Social History:

Provider Assessment

Patient Education: